Renal Transplantation in Children

INTRODUCTION

Various immunological, metabolic, and technical factors render pediatric recipients with end-stage renal disease unique from their adult counterparts. In addition, the potential for complications after renal transplantation is far greater in children than in adults. In this study, we retrospectively analyzed 83 pediatric recipients who underwent kidney transplantation at our institution from 1975 to 2004.

MATERIALS AND METHODS

From November 1975 to December 2004, 1523 renal transplantations were performed at our institution with 56 procedures in 83 pediatric patients (44 boys and 39 girls; age range, 7 to 17 years; mean age, 14.9 +/- 2.2 years).

RESULTS

Long-term follow-up revealed the following morbidities in 14 (16.3%) recipients: lymphocele in 7 (8.1%) patients, perirenal hematoma in 2 (2.3%), graft renal artery stenosis in 2 (2.3%), ureteral stenosis in 2 (2.3%), and ureteral anastomotic leak in 1 (1.2%). Six (7.2%) recipients with a functioning graft died during follow-up (five deaths were infection related, and the cause of one death was unknown). Five grafts failed (four for immunological reasons and one as a result of recurrent disease). The 1-, 3-, 5-year patient and graft survival rates were 98%, 93%, 92% and 91%, 78%, 67% for living related transplantations versus 98%, 91%, 90% and 92%, 76%, 65% for cadaveric transplantations, respectively.

DISCUSSION

Better outcomes for renal transplantation in children may be obtained by strict adherence to precise surgical techniques, better immunosuppressive management, and early diagnosis/effective treatment of complications.

Intra- and postoperative complications of donor nephrectomies

INTRODUCTION

Living-donor renal transplantation has become common worldwide. However, living-donor nephrectomy is not a complication-free procedure. This retrospective study reviews the intra-and postoperative risks and complications of donor nephrectomies at our institution between 1994 and 2002.

METHOD

Two hundred fifty-seven consecutive donor nephrectomy patients were evaluated using medical records and anesthetic charts.

RESULTS

The mean age of living donors was 42 +/- 12 years: 19 were older than 61 years, and 143 (55.6%) were women. Anesthesia for donor nephrectomy included general anesthesia, combined spinal-epidural anesthesia (CSE), general + CSE, and general + epidural anesthesia. We observed 51 intra- and postoperative complications in 26 patients. The minor complication rate was 10.1%. The duration of surgery was 3.56 +/- 0.26 hours (range, 2 to 5 hours). Serum creatinine levels were increased significantly (P < .05) on postoperative days 1, 3, and 5 compared with the preoperative levels (P < .05). There was no mortality.

CONCLUSIONS

Like other surgical operations, living-donor nephrectomy is associated with intra- and postoperative complications. Although these complications are minor, maximal efforts must be applied in the anesthetic approach to minimize donor complications, and donors should be informed about potential risks.

Severe Angioedema Caused by Banana Allergy UnderTacrolimus Immunosuppression

Occurrences of allergic reactions induced by various foods have been reported in pediatric liver graft recipients receiving tacrolimus immunosuppression. We describe herein a female infant, who was admitted to our hospital with life-threatening angioedema because of banana hypersensitivity, 8 months after orthotopic liver transplantation. Food allergies should be screened in all tacrolimus-immunosuppressed pediatric liver recipients who show suggestive clinical symptoms. Banana must be added to allergen batteries during etiologic investigations. Cyclosporine represents an option for drug conversion to prevent organ rejection.

Pulse Contour Cardiac Output System Use in Pediatric Orthotopic Liver Transplantation: Preliminary Report of Nine Patients

Anesthetic management of orthotopic liver transplantation (OLT) in pediatric patients is challenging in terms of intraoperative bleeding, fluid management, and hemodynamic monitoring. The pulse contour cardiac output (PiCCO) system, a relatively new device based on the single-indicator transaortic thermodilution technique, may be useful for intraoperative hemodynamic monitoring in pediatric patients. This is a preliminary report of PiCCO use in nine children (aged 9.8 +/- 4.7 years) undergoing OLT. Hemodynamic volumetric parameters monitored by the PiCCO system were mean arterial pressure (MAP), cardiac index (CI), intrathoracic blood volume index (ITBVI), extravascular lung water index (EVLWI), systemic vascular resistance index (SVRI), and stroke volume variability (SVV). All parameters were recorded at anesthesia induction (T0), at the end of the anhepatic phase (Tanhepatic), and at the end of operation (Tend). The PiCCO system revealed similar MAP, CI, EVLWI, SVV, and SVRI values at all measurement intervals. Despite similar central venous pressure measurements, ITBVI values indicated significantly lower values at Tanhepatic than at T0 (627 +/- 160 mL/m2 and 751 +/- 151 mL/m2, respectively, P = .013). There were no PiCCO catheter-related complications in any patient. These findings demonstrate that the PiCCO system is a safe, continuous, multiparameter invasive monitoring device for use in pediatric patients undergoing OLT. This system may provide valuable data during pediatric OLT and appears to be a promising monitoring tool in these patients.

Living-Related Liver Transplantation in Pediatric Patients

INTRODUCTION

Many developments in surgical technique, immunosuppression, and patient selection criteria have led to improved long-term patient and graft survival in pediatric patients receiving liver transplants. In this study, we examined the early results of 26 pediatric recipients who underwent 26 liver transplantations between January 2003 and December 2004 at our institution.

MATERIALS AND METHODS

The most common indications for liver transplantation were cholestasis in 10 patients (38.5%) and Wilson's disease in 8 (30.8%). Other indications were fulminant hepatic failure (4 patients, 15.4%), tyrosinemia (2 patients, 7.7%), Caroli disease (1 patient, 3.8%), and cryptogenic cirrhosis (1 patient, 3.8%). One recipient with Byler disease and two with tyrosinemia also had incidental hepatocellular carcinoma.

RESULTS

Of 26 patients, 24 (92.3%) underwent living-related liver transplantation and 2 (7.7%) underwent cadaveric transplantation. The medical records of all patients were retrospectively reviewed. Twenty-two of 26 survived with excellent graft function, showing 91.2%, 86.4%, and 81.6% at 3, 12, and 24 months graft and patient survival rates, respectively. Sixteen patients (61.5%) developed various morbidities with biliary and vascular complications being the most common. Four patients (15.3%) developed bile leaks. Four patients (15.3%) developed hepatic artery thromboses. Five patients (19.2%) developed life-threatening infections. Four patients (15.4%) died during the study period, three owing to infectious complications. The other patient died due to acute respiratory distress syndrome.

CONCLUSION

Despite technical difficulties and a donor organ shortage, the results of liver transplantation in pediatric patients with end-stage liver disease have demonstrated promising results at our institution.

Internal Jugular Versus Subclavian Vein Catheterization for Central Venous Catheterization in Orthotopic Liver Transplantation

The aim of this study was to compare incidence rates of mechanical and infectious complications associated with central venous catheterization via the internal jugular vein (IJV) versus the subclavian vein (SV) among 45 consecutive patients undergoing orthotopic liver transplantation (OLT) between January 2000 and June 2004. The subjects were divided into two groups according to the site of central venous catheterization (IJV or SV). We recorded each patient's physical characteristics, international normalized ratio (INR), partial thromboplastin time, platelet levels, number of puncture attempts, success/failure of central venous catheterization, duration of catheter placement, occurrence of catheter tip misplacement, arterial puncture, incidence of hematoma or pneumothorax, catheter-related infection, or bacterial colonization of the catheter. Senior staff anesthesiologists performed 22 SV and 23 IJV catheterizations for the 45 OLT procedures. The SV and IVJ groups both had minor coagulation abnormalities with slightly increased INR values at the time of catheterization. There were no significant differences between the groups with respect to success of central venous catheterization (100% for both), numbers of attempted punctures, duration of catheter placement, and incidence rates of mechanical and infectious complications. Both groups showed high frequencies of catheter tip misplacement, with right atrium as the site of misplacement in all cases. Two patients in the IJV group (8.7%) developed hematomas after accidental carotid artery puncture. The results suggest that, when performed by experienced anesthesiologists, central venous catheterization via the SV is an acceptable alternative to IJV catheterization for patients undergoing OLT.

The effect of anesthetic technique on early postoperative renal function after donor nephrectomy: a preliminary report

General and regional anesthesia may both be used successfully in donor nephrectomy although the use of regional anesthesia is rare. We compared the remaining kidney function during general (n = 10) versus combined spinal-epidural (n = 10) anesthesia for donor surgery. Blood biochemistry data were collected preoperatively and postoperatively, while renal function was assessed by scintigraphy and urine levels of microalbumin, creatinine, Na, K, Ca and creatinine clearance rate were measured/calculated in 24-hour urine samples collected preoperatively and on postoperative day 2. There were no differences preoperatively and on postoperative day 2 with respect to glomerular filtration rate, microalbuminuria, or creatinine clearance rate (P > .05 for all). There were also no differences between the groups with respect to other scintigraphic findings preoperatively and on postoperative day 2 (P > .05 for all). The results suggest that general or combined spinal-epidural anesthesia for donor nephrectomy have similar effects on the remaining donor kidney function.

Regional versus general anesthesia for donor nephrectomy: Effects on graft function

Various general and regional anesthesia methods are used successfully in living-donor kidney transplantation. This study compared kidney graft function after general versus combined spinal-epidural anesthesia for donor nephrectomy. The study groups included recipients who received grafts from donors who had undergone nephrectomy under general anesthesia (GA group; n=10), and recipients who received grafts from donors who had combined spinal-epidural anesthesia (CSE group, n=10). Standard continuous epidural anesthesia was administered during all transplantations. Graft function was assessed using scintigraphy and Doppler ultrasonography on days 3 and 7. Urine levels of microalbumin, creatinine, and creatinine clearance rate were measured/calculated in 24-hour urine samples collected on postoperative days 3 and 7. There were no differences on either day 3 or day 7 with respect to glomerular filtration rate, microalbuminuria, or creatinine clearance rate (P >.05 for all). There were also no differences between the groups with respect to other scintigraphic findings on day 3 or day 7 (P >.05 for all). Ultrasonography on day 7 showed significantly higher mean peak systolic flow in the main renal artery in the CSE group than in the GA group (P=.035). The results suggest that GA and CSE for donor nephrectomy have similar effects on kidney graft function in recipients.

Reduced joint pain after short-term duodenal administration of seal oil in patients with inflammatory bowel disease: comparison with soy oil

BACKGROUND

Rheumatic joint pain is a common extra-intestinal complication of inflammatory bowel disease (IBD). Because the high ratio of n-6 to n-3 fatty acids (FAs) of the Western diet might promote rheumatic disorders, we sought to compare the effects of short-term duodenal administration of n-3-rich seal oil and n-6-rich soy oil on IBD-related joint pain.

METHODS

Nineteen patients with IBD-related joint pain were included in the study; 9 had Crohn disease and 10 had ulcerative colitis. Ten millilitres seal oil (n = 10) or soy oil (n = 9) was self-administered through a nasoduodenal feeding tube 3 times daily for 10 days.

RESULTS

Compared with soy oil treatment, seal oil significantly reduced the duration of morning stiffness (P = 0.024), number of tender joints (P = 0.035), intensity of pain (P = 0.025) and the doctor's scoring of rheumatic disease activity (P = 0.025) at the end of the 10-day treatment period. Analysis of the effects as area under the curve (area between the curve and baseline, zero) for the entire period from start of treatment until 6 months' post-treatment suggested a long-lasting beneficial effect of seal oil administration on joint pain, whereas soy oil tended (not significantly) to aggravate the condition. Consistently, the serum ratios of n-6 to n-3 FAs (P < 0.01) and arachidonic acid to eicosapentaenoic acid (P < 0.01) were reduced after treatment with seal oil.

CONCLUSION

The results suggest distinctive, differential prolonged effects on IBD-related joint pain of short-term duodenal administration of n-3-rich seal oil (significant improvement) and n-6-rich soy oil (tendency to exacerbation).

Risk factors for postoperative respiratory complications in adult liver transplant recipients

To determine the types and the incidence of as well as risk factors for early postoperative (<30 days) respiratory complications in adult liver transplant (LT) recipients, we reviewed The data of 44 consecutive adult LT recipients who received their grafts from January 1995 through December 2002. The data included demographic features; primary diagnosis; number of intraoperative transfusions; preoperative and postoperative laboratory values; intraoperative and postoperative characteristics; and early postoperative (<30 days) mortality. Pulmonary atelectasis, pleural effusion, pneumonia, respiratory failure, and pulmonary edema were the respiratory complications investigated. Twenty-six patients (59.1%) developed at least one respiratory complication during the early postoperative period. The most frequent complication was pleural effusion (n = 18, 40.9%), followed by atelectasis (n = 13, 29.5%), pneumonia (n = 10, 22.7%), acute respiratory failure (n = 5, 11.4%), pulmonary edema (n = 3, 6.8%), and pneumothorax (n = 2, 4.5%). Compared to the patients who did not develop these problems, the affected cohort was significantly older (27 +/- 12 years vs 36 +/- 14 years, respectively; P =.039) and required more intraoperative transfusions (P =.005). Among the overall mortality rate of 15.9%, patients who developed pneumonia showed a significantly higher mortality (40.0% vs 8.8%, respectively; P =.037). Pleural effusion, atelectasis, and pneumonia are the main respriatory complications that occur in adult LT recipients. Patient age and intraoperative transfusion requirements are important predictors of early postoperative complications. Pneumonia is associated with a poor prognosis in this patient group.

Percutaneous dilational tracheotomy in solid-organ transplant recipients

Pulmonary complications, such as pneumonia and respiratory failure, are important contributors to posttransplantation morbidity and mortality among solid-organ transplant recipients. Percutaneous dilational tracheotomy (PDT) is cost-effective in critically ill patients who require prolonged mechanical ventilation; however, the literature lacks reports about the effectiveness of this procedure in organ transplant recipients. Between August 2001 and February 2003, five recipients underwent PDT in our intensive care unit: two kidney, two liver, and one heart transplant recipient. The respective mean values for age, weight and APACHE II score were 41 +/- 7 yrs (range, 33-51 years), 63 +/- 14 kg (range, 40-80 kg), and 23 +/- 9 (range, 15-35). All PDTs were performed at the bedside by an experienced staff anesthesiologist under endoscopic guidance using the Griggs forceps dilational technique. The mean interval from transplantation to PDT was 58 +/- 56 months (range, 8 days to 132 months). In all cases, the indication for PDT was prolonged mechanical ventilation due to acute respiratory failure. The mean duration of endotracheal intubation before PDT was 4 +/- 3 days (range, 1-8 days). Transient hypoxemia (n = 1) and mild extratracheal bleeding (n = 1) were the only early complications. There were no late complications (including peristomal infection) or deaths associated with the procedures. Among the two patients who survived their stay in the intensive care unit, the functional and cosmetic outcomes of PDT were excellent. We recommend this technique for prolonged airway management in solid-organ transplant recipients.

Early postoperative complications of pediatric liver transplantation: experience at one center

To evaluate the postoperative complications within the first month among 20 pediatric liver transplant recipients between April 1990 and March 2003 we retrospectively studied their medical charts to gather demographic data; primary diagnosis; operative duration; perioperative transfusions; time to extubation; length of intensive care unit (ICU) stay; mortality; perioperative laboratory values; and postoperative complications including respiratory, infections, renal, neurological, cardiovascular, and gastrointestinal tract (GIT) complications. Ten male and ten female patients of mean age 8 +/- 4 years had a mean operative duration, time to extubation, and length of stay in the ICU of 12.1 +/- 2.3 hours, 11.1 +/- 15.0 hours, and 7.2 +/- 5.5 days, respectively. The most frequent postoperative complication was respiratory (n = 14, 70%), followed by infections (n = 13, 65%), renal (n = 8, 40%), neurological (n = 7, 35%), cardiovascular (n = 4, 20%), and GIT (n = 4, 20%) infections. The overall mortality rate was 25% (n = 5). Compared with patients who survived, those who died displayed significantly lower perioperative platelet counts (P <.05), as well as a significantly higher incidence of postoperative neurological disorders (P =.031), and cardiovascular complications (P =.032).